11/27/20071 doe corporate operating experience program, doe o 210.2 briefing to the operating...

11/27/2007 1

DOE Corporate Operating Experience Program,

DOE O 210.2 Briefing to the Operating Experience Committee Meeting

And the ISM Champions WorkshopNovember 27 & 29, 2007

-----------------------------------------------------------

Eugenia L. BoyleOccurrence Reporting &

Operating Experience Program ManagerOffice of Analysis (HS-32),

Office of Corporate Safety Analysis Office of Health, Safety and Security

[email protected]

mailto:[email protected]

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Contents

Current Status of DOE O 210.2 Implementation – Contractor, Field, HQ, and Lead Office

Related OPEX Commitments to DNFSB 2004-1 and Status

Lead Office OPEX Initiatives

Lessons Learned Program Survey Results

Formation of an Operating Experience Committee

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DOE O 210.2 Status

DOE Order 210.2, DOE Corporate Operating Experience Program – Issued June 12, 2006.

Order required the Contractor Requirements Document (CRD) to be incorporated into affected contracts by December 12, 2006.

The CRD requires Contractors to incorporate the CRD into affected sub-contracts by June12, 2007.

Four Regional Implementation Workshops were held in October and November 2006.

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DOE O 210.2 - Contractor Implementation Status

62% in contracts now 31% implemented now

PSO#

CONTR. # IN CONTRACTS # IMPLEMENTEDCOORDINATORS

IDENTIFIED

Now

End of

Year Later Unknown Now

End Of

Year Later Unknown

EE 1 0 1 0 0 0 0 0 0 1

EM 22 11 0 0 11 5 2 1 14 20

FE 1 1 0 0 0 0 1 0 0 1

NA 7 4 1 0 2 2 0 1 4 5

NE 3 3 0 0 1 2 0 0 3

RW 1 0 1 0 0 1 0 0 0 1

SC 15 12 1 0 2 6 2 3 4 11

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DOE O 210.2 - DOE Field Implementation Status

36% implemented now

PSO# FIELD SITES # IMPLEMENTED

COORDINATORS IDENTIFIED

Now

End Of

Year Later Unknown

EE 1 0 0 0 1 1

EM 9 1 1 1 6 5

FE 1 1 0 0 0 1

NA 8 2 0 0 6 7

NE 1 0 0 0 1 1

RW 1 1 0 0 0 1

SC 12 4 0 2 6 10

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DOE HQ Implementation Status

The Office of Energy Efficiency has implemented DOE Order 210.2, "DOE Corporate Operating Experience Program" as part of a tailored, graded approach under the Integrated Safety Management System. They are currently in the process of updating and revising their HQ Functions, Responsibilities and Authorities Manual (FRAM).

The Office of Science is developing documentation to define and implement its Operating Experience and Lessons Learned Program through its web-based Science Management System (SCMS). Implementation at the PSO level is expected in the next few years. Science laboratories are generally strong in their use of operating experience information and do not rely on the existence or performance of a Headquarters-based system to effectively use operating experience information to improve their safety performance.

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DOE HQ Program Implementation Status (cont’d)

The Office of Fossil Energy is involved in the following OPEX implementation activities:

1.Representation on the Operating Experience Committee.

2.Monitoring ORPS reports relative to FE HQ or sites and conducting investigations as required.

3.Reviewing best practices, where applicable.

4.Monitoring and dissemination of all total recordable cases, lost workday cases, near misses, etc..

5.Active involvement in the CAIRS system.

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The National Nuclear Security Administration is involved in the following OPEX implementation activities:

1.Requested that all NNSA organizations HQ/sites appoint coordinators and that sites incorporate DOE O210.2 into M&O Contracts - August 8, 2007.

2.Issued expectations for OPEX programs after a survey of the Field - November 26, 2007.

3.Is developing HQ Procedure for implementation of OPEX program - target November 2007.

4.Planning self-assessment of HQ OPEX programs implementation - target December 2007.

5.Planning assessment of two NNSA sites to validate OPEX program implementation - target January / February 2007.

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The Office of Civilian Radioactive Waste Management (OCRWM) has a formal lessons learned process that is part of our Corrective Action Program (CAP). The CAP program tracks to closure identified issues and the corrective actions that are developed to prevent recurrence. In addition, the OCRWM Trending Program identifies monitoring, emerging, and adverse trends and requires line management actions to address the trends. Formal quarterly reports on the trends and corrective actions are provided to senior management.

The OCRWM CAP is a key requirement for the License Application that will be evaluated by the U.S. Nuclear Regulatory Commission in the licensing of the Yucca Mountain Repository and status reports are periodically provided during the public quarterly management review meetings. The Director and senior management team routinely review operating safety metrics and metrics from the CAP during their Monthly Program Reviews.

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The Office of Nuclear Energy has a designated OPEX Program Coordinator and a lessons learned database (called NEATS - NE Action Tracking System) for the past 3 years. NEATS is used to forward Lessons Learned (LLs), good practices, and information about relevant issues to our sole field office (DOE-ID) at the INL for their information, use, and to solicit feedback on actions taken, as appropriate. DOE-ID receives HSS LLs daily, generates its own LLs, and prepares a daily summary that includes LLs for distribution to all INL contractors. NE will also be expanding its OPEX implementation activities as it receives further guidance/direction from HSS and/or the OPEX committee.

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The Office of Environmental Management continues to utilize the DOE Corporate Lessons Learned Database, (maintained and managed by HSS), to report and disseminate lessons learned. The Office of Acquisition and Project Management (EM-50) will lead the coordination with EM/HQ and Field sites for submission of lessons learned in project management to the HSS database and the EM Communications Portal.

In addition, the Chief Operating Officer (EM-3) established an EM Operations Lessons Learned Program in 2006 to promote sharing of operational experiences throughout the EM complex. Based on factors including risk and costs, operational facilities and projects are selected to share lessons learned in: Safety; Acquisition Strategy & Contract Management; Regulatory Compliance; Technology; Engineering Design & Construction; Funding & Resources; and Communications. EM has completed more than 10 operations lessons learned, including Rocky Flats Closure Project, River Corridor Cleanup Project, Hanford Waste Treatment Plant, Savannah River Salt Waste Processing Facility, etc. EM Operations Lessons Learned are presented at the monthly EM Field Managers Video Conferences and the presentations are posted on the EM Communications Portal.

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Lead Office Implementation Status

Lead Office: Office of Health, Safety and Security

-Operating Experience Committee has been Chartered.

-HSS Functions Responsibilities and Accountabilities (FRA) has been updated to Reflect Functions.

-Office of Corporate Safety Performance is formalizing procedures that describe the processes used by the Office of Analysis in conducting the program.

- Working in conjunction with the EFCOG ISM Working Group – ORPS, Electrical Safety Improvement Project, Feedback and Improvement, HPI.

-HSS Continues to Establish Contacts with External Agencies and Review of External Experience.

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Commitments from DNFSB 2004-1

Three Operating Experience Program-Related Commitments

Commitment 17: Complete Department-wide formal review of Columbia and Davis-Besse events, and develop consolidated Department-wide Action Plan.

DOE Action Plan – issued July 2005 identified Ten DOE Lessons Learned, Five with 20 unique Actions. Complete – July, 2005.

Commitment 18: Develop a Comprehensive Operating Experience Program.

DOE O 210.2 fulfilled this commitment. Complete – June, 2006.

Commitment 19: Demonstrate Performance of DOE Operating Experience Program.

Due by December 12, 2007. DNFSB has continued interested in implementation progress. Not complete.

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DNFSB 2004-1 Commitment 17

Progress Report: Commitment was Met, Actions Ongoing

While the formal review of the Columbia Shuttle and Davis Besse Nuclear Reactor events has been completed,

additional actions remain as defined in the Department-wide Action Plan.

Complete Department-wide formal review of Columbia and Davis-Besse events, and develop consolidated Department-wide Action Plan.

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DNFSB 2004-1, Commitment 17Columbia / Davis-Besse OPEX Related Actions

Action #1.c. - Memo to Establish DOE Operating Experience Committee – Completed.

Chartered as a subgroup of the ISM Champions Council.DOE program office and DOE and Contractor field

representatives will serve on this committee.

Action #1.e. - Sponsor Periodic Safety Forums for Sharing Lessons Learned

– First Operating Experience Committee (OEC) Meeting to be held November 27, 2007 at BNL.

– Future OEC Meetings/Workshops will continue to coincide with ISM Champions Council Meetings

Action Plan, Lesson Learned #1 : Operating Experience.

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Lead Office OPEX Initiatives

DOE has Implemented a Corporate Safety Indicator Process -

DOE's Corporate Safety Indicator process has been modified to include Corporate Sustainability. The concept of Corporate Sustainability, along with the analysis of other corporate safety indicators, has been briefed to the Deputy Secretary for the last three quarters.

BP Fire Lessons LearnedHSS issued ES&H Advisory 2007-02, Safety Culture

Weakness Cited in BP Accident, based on the findings and recommendations of the independent safety review of BP U.S. refineries.

HSS is determining whether to convene a DOE-wide review team to identify other DOE Lessons Learned from this report.

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Lead Office OPEX Initiatives (cont’d)

External Operating Experience: HSS has made formal contacts with several External Agencies and routinely searches External OPEX Sources.

• U.S. Chemical Safety and Hazards Investigation Board

• Nuclear Regulatory Commission

• National Aeronautics and Space Administration

• Naval Safety Center

• Institute of Nuclear Power Operations

Additional Contact Efforts Continue.

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Separate and clarify the Criteria for Fires and Explosions. New Criteria for Hazardous Electrical Energy Control using the

Electrical Severity Measurement Tool and for Other Hazardous Energy Control.

Technical Safety Requirements (TSR) - revised to remove criticality

Criticality Safety revised to capture TSR violations Facility Operations revised Management Concerns revised


Proposed Revision of DOE M 231.1-2, Occurrence Reporting Criteria:

HS-30 is reviewing and finalizing proposed changes to the occurrence reporting criteria. Will submit for REVCOM review in early 2008.

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Near Misses - Revised Definition:

10 (3) 1-3† A near miss to an otherwise ORPS reportable event, where something physically happened that was unexpected or unintended and significant consequences were avoided only by chance because either:

a) no controls or protective equipment were in place to prevent more severe consequences, or

b) the controls or protective equipment were ineffective.

The significance category assigned to the near miss should be based on an evaluation of the potential risks and planned or anticipated corrective actions.

The proposed changes are intended to correct known reporting problems and enhance the Corporate Safety Indicator Process.


Proposed Revision of DOE M 231.1-2, Occurrence Reporting Criteria (cont’d):

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1. Safety Bulletins - 5

2. Safety Advisories - 5

3. Operating Experience Summary – 7 Issues containing 22 Articles

4. Suspect/Counterfeit Data Collection Sheets – 131

5. Lessons Learned – 200 approved

6. Facility Call Sheets – 86

In CY 2007, HS-30 published the following OPEX products:


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1. Safety Bulletin 2007- 01, Compressed - Gas Cylinder Safety

2. Safety Bulletin 2007- 02, Hexavalent Chromium Update

3. Safety Bulletin 2007- 03, Lead Safety Awareness

4. Safety Bulletin 2007- 04, Thoriated Weld Rods

5. Safety Bulletin 2007- 06, Unwanted Chemical Reactions

Safety Bulletins


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1. Safety Advisory 2007- 01, Valley Fever

2. Safety Advisory 2007- 02, BP Safety Culture

3. Safety Advisory 2007- 03, OSHA Revises Electrical Safety Standards

4. Safety Advisory 2007- 04, Startup Reviews

5. Safety Advisory 2007- 05, Substance Abuse

Safety Advisories


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Operating Experience Summary Articles


1. In the Event of Fire, Follow Emergency Procedures2. Excavator Accidents can be Deadly3. Safety XChange Reports on Best Practices of 20064. Fluor Hanford Develops Training Material on Hazards Involving Neutral Conductors 5. Ladders: What Goes Up Must Come Down — Safely6. Valley Fever Cases Reported at Lawrence Livermore National Laboratory7. Operating Vehicles or Equipment while Fatigued can be Fatal8. Failure to Verify Voltage Results in Electrical Near Miss9. Aerosol Can Explodes Inside a Hot Truck and Damages Windshield10. PPE and Engineered Controls can Prevent Welding Exposure to Hexavalent Chromium 11. Inadequate Industrial Job Planning has Unintended Consequences

11/27/2007 24

Operating Experience Summary Articles (cont’d)


12. Is There a Fire Hazard Underneath Your Desk?13. Always Consider Potential Electrical Hazards in Non-Electrical Work14. Preventing Heat-Related Illness15. Poor Job Planning Results in Electrical Worker Fatality16. Lessons Learned from Leak at British Reprocessing Plant17. Damaged Powered Air Purifying Respirator Hoses18. Safe Use and Installation of Fall Protection Anchors19. NRC Identifies Recurring Operability Issues with Emergency Diesel Generators20. Near Miss - Roll Bar on Riding Mower Knocks Down Window Air Conditioner21. Are Proper Cold Weather Protection Measures in Place at Your Site?22. OSHA Issues New Instruction on Combustible Dusts

11/27/2007 25

In October, 2007, a Lessons Learned Program Survey was distributed to key contractor personnel across the complex.

There were 25 respondents from more than 21 sites.

The following slides show some of the results from the survey.

Lessons Learned Survey Results

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According to the survey, the top five sources used to generate organizational Lessons Learned Notices were:

DOE Corporate Operating Experience LL Database 72%

Critiques and Investigations 68%

Occurrence Reporting and Processing System (ORPS) 64%

Accident, Incident, Injury Reports 52%

Daily Operational Experiences 44%

Lessons Learned Survey Results (cont’d)

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The following is the stated percentage of contractors who routinely submit internal Lessons Learned to the DOE Corporate Operating Experience Lessons Learned Database.

Yes: 56%

No: 44%


Question: What can we do to increase this percentage?

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The following is the stated percentage of Lesson Learned Programs that have a system to track corrective actions made in response to a Lessons Learned Notice?

Yes: 52%

No: 48%


Question: What can we do to increase this percentage?

11/27/2007 29

The responses below were selected to complete the following sentence:

We have implemented the new DOE Order....

Yes No

...into our site Operations 60% 40%

...into our site Maintenance and Work Planning 60% 40%

...into our site Work Processes 68% 32%

...into our site Training 56% 44%

...into our site Design and Construction 48% 52%


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The responses below were selected to complete the following sentence:Our site has established metrics that measure the...

Strongly Disagree

Disagree No Opinion

Agree Strongly Agree

…Lessons Learned program performance.

20% 4% 24% 48% 4%

...effectiveness of actions implemented from Lessons Learned Notices.

24% 12% 28% 28% 8%

...effectiveness of the Lessons Learned program.

20% 4% 24% 48% 4%

...user feedback that documents the fact that a Lessons Learned Notice(s) was beneficial to the user and operations (e.g. application of a Lessons Learned resulted in process changes that made operations safer).

20% 12% 32% 24% 12%


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The responses below were selected to describe the contractors’ opinion of the following sentence:

Our site prepares and issues Lessons Learned reports, summaries and/or charts for Senior Management review.

Strongly Disagree 2%

Disagree 4%

No Opinion 8%

Agree 64%

Strongly Agree 12%


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The following is the stated frequency for issuing Lessons Learned reports, summaries, and/or charts.

Monthly 44%Quarterly 40%Bi-annually 4%Annually 0%Not applicable 20%


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The following is the stated overall satisfaction with the DOE Corporate Operating Experience Program.

Very Dissatisfied 0%

Dissatisfied 8%

No Opinion 16%

Satisfied 72%

Very Satisfied 4%


Question: What can we do to increase the percentage of Satisfied and Very Satisfied?

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The following is the stated overall satisfaction with the Society for Lessons Learned Sharing (SELLS) group.

Very Dissatisfied 0%

Dissatisfied 0%

No Opinion 4%

Satisfied 56%

Very Satisfied 40%


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Operating Experience Committee (OEC)

Establishment of a DOE Operating Experience Committee

The purpose of the Department of Energy (DOE) Operating Experience Committee (OEC) is to support line management within DOE and the DOE community in developing and sustaining effective operating experience programs so that lessons from internal and external operating experience lead to improvement in future operational and safety performance.

The OEC will facilitate management and worker communications to promote the sharing of operating experiences and associated best practices for using operating experience to improve future performance.

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The DOE Operating Experience Committee has been Chartered as a Subgroup of the ISM Champions Council Will meet Action 1.c of the Columbia-Davis Besse Action Plan Will strengthen the feedback and improvement ISM core function Will provide increased Federal leadership and involvement in the review of operating experience The SELLS charter will be cancelled. In order to realize the benefits of learning from external operating experience, the OEC will open its membership to other government agencies, contractors, and private sector companies and individuals

Operating Experience Committee (OEC) (cont’d)

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Designated members of the Committee consist of:

(1) the designated DOE and Contractor Operating Experience Program Coordinators (as defined in DOE O 210.2),

(2) the Director, Office of Analysis within DOE’s Office of Health, Safety and Security, and

(3) Chief of Nuclear Safety (CNS) and Chief of Defense Nuclear Safety (CDNS), or their designated representatives.

Operating Experience Committee (OEC) (cont’d)

Associate membership in the Committee is open to: All DOE federal and contractor employees, as well as to external representatives interested in sharing operating experiences and associated best practices.

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Thank you for your attention!

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